Basic Information
| Provider Information | |||||||||
| NPI: | 1659428365 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CIVITARESE | ||||||||
| FirstName: | BARBARA | ||||||||
| MiddleName: | JEAN | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 840853 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752840853 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9722331999 | ||||||||
| FaxNumber: | 9722333666 | ||||||||
| Practice Location | |||||||||
| Address1: | 1500 CITYWEST BLVD | ||||||||
| Address2: | STE. 300 | ||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770422300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7136204000 | ||||||||
| FaxNumber: | 7134584229 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/04/2007 | ||||||||
| LastUpdateDate: | 04/28/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/28/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | AP103149 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | C088619C8 | 05 | TX | MEDICAID | 88619C | 01 | TX-BLUE SHIELD | OTHER | 109946704 | 05 | TX | MEDICAID | 430027389 | 01 | TX | RAILROAD MEDICARE | OTHER | 1698385 | 05 | LA | MEDICAID |